Care management billing

Priority Health will reimburse, fee for service, for care management codes. Reimbursement is available to primary care and specialty physicians.

Eligible patients

Patients enrolled in care management should:

  • Be classified as moderate or high risk based on health history
  • Have one or more chronic conditions
  • Have a completed care plan which includes the documentation requirements listed above
  • Receive care by a trained qualified health provider* (QHP) and working within a structured care team

Reimbursement rates

The reimbursement rates for these codes are listed in our standard fee schedules for your contract.

Request a fee schedule.

Billable care management codes

The CPT and HCPCS manuals define billing and coding requirements for both physician and non-physicianQHP* care management services.

MIPCT:For additional guidance on code use and documentation standards, visit the Michigan Primary Care Transformation Demonstration website, mipct.org.

Click a code in this chart to go to billing help for that code.

2015 care management coverage
Code / HMO/POS/PPO, self-funded, Medicare / Medicaid
G9001 / Coordinated care fee, initial assessment
Covered benefit; $0 member liability / Not covered
G9002 / Coordinated care fee, individual face-to-face visit
Covered benefit; $0 member liability / Not covered
G9007 / Coordinated care fee, scheduled team conference
Covered benefit; $0 member liability / Not covered
G9008 / Coordinated care fee, scheduled conference, physician oversight service
Covered benefit; $0 member liability / Not covered
98966 / Telephone assessment and management service provided by a qualified non-physician health care professional* to an established patient, parent or guardian; 5-10 minutes of medical discussion
Covered benefit; $0 member liability / Not covered
98967 / Telephone assessment (see above), 11-20 minutes of medical discussion
Covered benefit; $0 member liability / Not covered
98968 / Telephone assessment (see above), 21-30 minutes of medical discussion
Covered benefit; $0 member liability / Not covered
99490 / Chronic care management services
Medicare only: Covered benefit; copay and/or deductible may apply / Not covered
99495 / Transitional care management: moderate complexity, patient contact within 2 business days of discharge and a face-to-face within 14 calendar days of discharge
Covered benefit; copay and/or deductible may apply / Covered benefit, copay may apply
99496 / Transitional care management: high complexity, patient contact within 2 business days of discharge and a face-to-face within 7 calendar days of discharge
Covered benefit; copay and/or deductible may apply / Covered benefit, copay may apply

Special process for care management G-code and QHP telephone visit claim payment

Priority Health has a unique process for paying G-code and telephone visit care management services.

  1. Practices bill care management G-code and telephone visit CPT services with their practice charges.
  2. Priority Health auto-adjudicates claims, applying a $0 payment.
  3. On the Remittance Advice, the $0 payment yields full allowed dollars as provider liability.
  4. The Remittance Advice processing code is CO96, "no compensation allowed for this service - reporting only."
  5. The member'sclaim explanation displays $0 member liability. No copayment or deductible applies.
  6. Every 60 days, Priority Health batches a payment for the full allowed amount of each practice's billed G-codes and CPT codes with no member copayment or deductible.
  7. These payments are processed with a paper check.
  8. The check payment and Remittance Advice report are mailed to the provider's claims remittance advice address.
  9. A Remittance Advice report designates claim detail such as member demographics, billed codes and date of service.

G9001, Coordinated care fee, initial assessment

Documentation requirements

  • Date(s) of visit(s)
  • Appointment duration
  • Care manager name and credentials
  • Comprehensive patient assessment
  • Name of the caregiver and relationship to patient, if caregiver is included with the visit
  • Diagnoses discussed
  • Treatment plan, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Care plan, including challenges and interventions
  • Patient understanding and agreement with care plan
  • Physician coordination activities and approval of care plan
  • Name of member's PCP

Tips

  • Care provided by a QHP*
  • Initial care management assessment only
  • May be billed once annually for patients with ongoing care management
  • Must include a face-to-face visit with the patient
  • Work must encompass a minimum of 30 minutes, some of which may be without the patient present
  • Physicians may also billG9008 if care meets billing and documentation requirements
  • Date of service = date the assessment was completed

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G9002, Coordinated care fee, individual face-to-face visit

Documentation requirements

  • Date(s) of visit(s)
  • Appointment duration
  • Care manager name and credentials
  • Name of the caregiver and relationship to patient, if caregiver is included with the visit
  • Diagnoses discussed
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Care plan update
  • Patient understanding and agreement with care plan
  • Physician coordination activities and approval of care plan
  • Name of member's PCP

Tips

  • Care provided by a QHP*
  • Must includea face-to-face visit with the patient
  • May include caregiver involvement
  • Focused discussion of the patient's care plan
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Ongoing care plan development
  • Code may be billedone time per day

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G9007,Coordinated care fee, scheduled team conference

Documentation requirements

  • Date(s) of conference(s)
  • Conference duration
  • Care team names and credentials
  • Diagnoses discussed
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Care plan updates
  • Physician coordination activities and approval of care plan

Tips

  • Scheduled care team meetings: physician, care manager and other QHPs*
  • Care provided by a physician
  • Patient is not present
  • Care plan developed,decisions documented
  • Self-management goals
  • Billed under physician's name
  • Code may be billedone time per day

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G9008, Coordinated care fee, scheduled conference, physician oversight service

Documentation requirements

  • Date(s) of visit
  • Appointment duration
  • Care team member names and credentials
  • Name of the caregiver and relationship to patient, if caregiver is included with the visit
  • Diagnoses discussed
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Preparation of shared care plan written by case manager
  • PCP approval of care plan
  • Patient understanding and agreement with care plan
  • Physician coordination activities and approval of care plan

Tips

  • Care must be provided by a physician.
  • Service must include patient face-to-face:Either face-to-face with PCP, patient and care manager,OR face-to-face with patient and care manager, with care manager/PCP direct involvement on a separate occasion.
  • Patient must formally agree to the care plan.
  • Service must include completion of patient assessment.
  • Bill code after the patient enrolls in a care management program.
  • A PCP evaluation and management visit must be billed in close proximity to this visit date.
  • G9001 or G9002 must also be billed in close proximity to this visit date.
  • This code may only be billed one time, per practice, during the time that patient is a member of the practice.

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99487, Complex chronic care coordination, first hour physician directed, no face-to-face visit, per calendar month

Documentation requirements

  • Date(s) of contacts
  • Contact duration
  • Care team names and credentials
  • Diagnoses discussed
  • Development and/or maintenance of a shared care plan
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Discussion notes for each contact

Tips

  • Care must becoordinated by a physician and the care team.
  • Patient does not need to be present for team conferences.
  • Patient contact may be by phone or face-to-face.
  • Includes coordination of services with health care community:Physicians, facilities, ancillary providers, community agencies, etc.
  • Note the cumulative services provided in one calendar month.
  • Cumulative time per patient must exceed 30 minutes.
  • Bill one unit per month for cumulative time of 31-74 minutes.
  • Billed date of service:Use thedate on which services were last provided during the month.

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99489, Add-on code to 99487, each additional 30 minutes

Documentation requirements

  • Date(s) of visit and/or contacts
  • Appointment or contact duration
  • Name of caregiver and relationship to patient, if caregiver is included with the visit
  • Care team names and credentials
  • Diagnoses discussed
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Discussion notes for each contact

Tips

  • Code should only be billed in cases where the cumulative time exceeds 90 minutes.
  • Care is coordinated by a physician and the care team
  • Patient does not need to be present for team conferences.
  • Add-on code to 99487
  • Multiple units may be billed
  • Billed date of service:Use thedate on which services were last provided during the month.

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99490, Chronic care management services

Documentation requirements

  • Date(s) ofvisit(s) and/or contacts
  • Appointment or contact duration
  • Care team names and credentials
  • Diagnoses discussed
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Comprehensive care plan
  • Discussion notes for each contact
  • Development and/or maintenance of a shared care plan
  • As appropriate: Treatment plan, self-management education, medication therapy, visit factors, unmet care, physical status, emotional status, community resources, readiness to change

Tips

  • Management must take at least 20 minutes of staff time over the course of one month.
  • Work must be directed by a physician or qualified health professional.
  • Patients must have two or more chronic conditions that place them at a significant risk of death, acute exacerbation/decompensation, or functional decline.
  • Care plan must be implemented, revised or monitored during the course of care.

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99495, Transitional care management: moderate complexity, patient contact within 2 business days of discharge and a face-to-face within 14 calendar days of discharge

Documentation requirements

  • Date of office visit
  • Date of phone visit
  • Diagnoses discussed
  • Refer to CPT Manual for additional documentation requirements.

Tips

  • Care is provided by a physician.
  • Code is intended to be used in place of an office-based evaluation and management service.
  • Patient contact must occur by phone within 2 business days of discharge. This call should include medication reconciliation.
  • An office visit within 14 calendar days of discharge is also required.
  • The billed date of service should be the 30th day post discharge.
  • Search cms.gov for helpful reference materials regarding transitional care management services.

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99496, Transitional care management: high complexity, patient contact within 2 business days of discharge and a face-to-face within 7 calendar days of discharge

Documentation requirements

  • Date of office visit
  • Date of phone visit
  • Diagnoses discussed
  • Refer to CPT Manual for additional documentation requirements.

Tips

  • Care is provided by a physician.
  • Code is intended to be used in place of an office-based evaluation and management service.
  • Patient contact must occur by phone within 2 business days of discharge. This call should include medication reconciliation.
  • An office visit within 7 calendar days of discharge is also required.
  • The billed date of service should be the 30th day post discharge.
  • Search cms.gov for helpful reference materials regarding transitional care management services.

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*QHPs include RNs, certified NPs, PA-Cs, licensed Master social workers (LMSWs), psychologists (LLPs and PhDs.), certified diabetic educators (CDEs), Registered Dieticians, Masters'-trained nutritionists, clinical pharmacists and respiratory therapists.

Last modified: 4/10/2015

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